While the opportunities to improve patient care outcomes and cost-effectiveness within the U.S. healthcare system through the development of various types of accountable care organizations (ACOs) are robust and multidimensional, so, too, are the cultural, process, strategic, and technological challenges, industry experts agree.
That complex picture emerged clearly during a breakout session Wednesday at the World Health Care Congress + Exhibition, being held at the Marriott Wardman Park Hotel in Washington, DC. The panel discussion was moderated by Lindsay Dunn, an editor at Health Forum, a division of the American Hospital Association. The other panelists were Barbara Adams, vice president of innovative technology services at Texas Health Resources (Arlington); Adam Wilcox, director of healthcare informatics at Intermountain Healthcare (Salt Lake City); Scott Berkowitz, M.D., medical director, accountable care, at Johns Hopkins Medicine (Baltimore); and Benjamin Zaniello, M.D., director of medical population health informatics at the Seattle-based Providence Health & Services.
Asked what elements are truly foundational in terms of laying the IT foundation for accountable care, Texas Health Resources’ Adams said, “I’ve spoken often about this. There are four building blocks in our world. The first one,” Adams said, “is the EMR [electronic medical record] That really is ‘table stakes’ right now. The second is a data warehouse. We don’t have the luxury of having all of our providers on a single EMR, and in that regard, we really rely on our data warehouse. The third one,” she said, “is a set of analytical tools—dashboards, BI [business intelligence], and so on. And the fourth element, which we haven’t fully implemented yet—is population management, which encompasses outreach campaigns, and efforts to close gaps in care.”
Asked how he and his colleagues make decisions about which data sets to use to support clinical decision support at the point of care, versus which data sets to use to support broad, strategically focused, system-wide analytics, Johns Hopkins Medicine’s Berkowitz said, “We’re still in the developmental phase. But we use the data in a lot of different ways, first of all, in terms of executing on care management interventions. We determine who the high-risk members of the population are, and we bring in the care managers in real time,” Berkowitz reported.
“We’re trying to develop expertise in terms of determining who the patients in our population are who do not have primary care,” he continued. “In fact, in an academic medical center environment, a lot of patients are actually attributed to us through specialists. We’re also doing dashboarding,” he said, and added that “We provide registry information to physicians, high-risk patient lists. There are certain things we’re able to do in real-time,” he said, while some processes are not yet “real-time.” When truly real-time sharing isn’t possible, he said, “We’re focusing on quickly collecting information and sharing it after the fact.”
Different Needs in Different Types of ACOs
Does it actually matter exactly how patient care organizations manage and share data that relates to different ACO ventures they’re involved in? Yes, absolutely, Texas Health Resources’ Adams said. “Yes—you need to build a crosswalk of your different ACO measures,” she said, “because once you do that, build a bridge, you can reference back to which measures you’re reporting on. It’s not one set of reports that goes to the payers, it’s different reports involving numerous different measures.”
Given the fact that nearly every patient care organization involved in ACO-type and risk-based contracts is working with multiple payers, Dunn asked, how can physicians gain competency and fluency in working with many different sets of data from numerous different initiatives or programs?
“That’s a real challenge,” Hopkins Medicine’s Berkowitz said, noting that “It’s not even just measures” that are involved when a patient care organization is involved in multiple risk-based contracts that require active case management; “it’s interventions, and knowing what support might be needed for certain payer lines. We are an all-payer state in Maryland, so we’re able to spread that [set of tasks and responsibilities], on the inpatient side, across some of our payer lines; but outpatient, it’s different. I’m a cardiologist,” Berkowitz noted; “but for primary care docs, especially, it can be very challenging. We try very hard to create measure sets and dashboards. There are more similarities than differences between and among these programs,” he added, “and I try to emphasize that. But making sure products can get to the sites of care effectively, and maximizing resources—it’s a challenge to help the physicians and providers.”
What’s more, Texas Health Resources’ Adams noted, when one gets down to granular levels of operations, things becoming even more challenging in ways. “We’ve found that between the different payers, the ranges [around performance, even on the same measures] were different,” she reported. “For example,” she said, “I still needed my docs to document for tobacco cessation advisement or hemoglobin a1c levels. But,” she said, given all the different levels of performance associated with the same measures, but in contracts with different payers, “I had our docs meet the measures at the highest level, to meet all the requirements of the different payers.”